Peer education is powerful: how abortion counselors care for patients

Zoleka Gqumisa is an abortion counselor in Khayelitsha. She works at three different clinics, and sees over twenty clients a day. At the Nolungile Youth Clinic her clients are mostly young women between the ages of 16 and 25, many still in school and pregnant for the first time.

At a gathering in Gugulethu in 2012, Zoleka noticed that a woman was smiling at her. Unsure of how she knew her, Zoleka asked her whether they had met before. The woman whispered,

‘Yes, from the clinic. You helped me very much’, she said. ‘I was so scared, and you made me calm. The procedure went well. I don’t like to tell others about it, to tell them that I had an abortion done. But I was protected at the clinic’.

Women presenting for abortions at public health clinics in South Africa have had to make difficult decisions. Their social context determines that they must be sexually available to their male partners, but that, should this result is an unwanted pregnancy, they are to blame. Research has shown that the primary reason given by most women for abortion is socio-economic.

Despite the inherent responsibility that a woman takes in ending an unwanted pregnancy because she cannot provide for the baby, social stigma surrounding abortion remains rampant. Many women fear that they will be ostracized by their friends and families, that they will be condemned by their churches and communities, and that they will be ill-treated by the staff at the clinic. They also fear the procedure itself – that it will be painful, humiliating, harmful to their health and damaging to their future capacity to bear children.

It is for these reasons that the educational and supportive roles played by abortion counselors are so crucial. Zoleka and her colleague, Nomafu Booi, are the only dedicated abortion counselors working in the Western Cape’s public health sector. According to the Provincial Government of Western Cape’s Sexual and Reproductive Health division, they are in fact the only two abortion counselors in South Africa that are attached to a public health facility. The work done by Zoleka and Nomafu is part of the City’s commitment to providing women with comprehensive healthcare at its clinics, rather than scattering these services across different sites. Instead of a stand-alone service, offered at only a small number of clinics, termination of pregnancy should be available to women as one component of women’s healthcare, and it should be provided together with other services, including screening for sexually transmitted infections and HIV, pap smears and sexual abuse counseling.

Abortion was legalized in South Africa in 1996 with the passing of the Choice on Termination of Pregnancy Act. The Act mandates that woman who seeks an abortion in the public health sector must be provided with counseling. The purpose of counseling is to explain to a woman that it is up to her to decide whether or not to have the procedure, and that she alone (rather than her family, or the man with whom she has conceived) must make this decision.

Zoleka and Nomafu use their counseling sessions to answer whatever questions women may have, including about the abortion procedure itself. They also provide women with information about pregnancy, family planning, HIV testing, and the prevention and treatment of sexually transmitted diseases.

A third of women in South African become pregnant by the age of 19. These high rates of teenage pregnancy are often blamed on irresponsible sexual behaviour and on the failure of young women in particular to use contraception. But this belies the complex social dynamics that determine how and when South African women have sex, whether they use condoms, or if they have been taught the biology of conception and pregnancy. Nor do these explanations account for the high rates of violence that women confront, or the fact that, for many women in South Africa, the only sex they know is coerced. For these women, government safe sex campaigns that hinge on messages about ‘taking responsibility’ and ‘avoiding risk’ are irrelevant. The slogan of the government’s extensive HIV Counseling and Testing campaign, during which an alleged 15 million people were tested for HIV, was ‘I am responsible, you are responsible, South Africa is taking responsibility’. For women who are unable to choose when and how to have sex, ‘taking responsibility’ becomes a luxury. What’s more, if their apparent failure to listen to these messages translates into blame and derision at health facilities, in their communities, and in their families, this contributes to the isolation of women who already constitute the most marginal groups in our society.

One reason that women are given insufficient information about contraception is that, in many cases, the nurses themselves have not received adequate and updated training. In recent years, the provincial government has collaborated with organisations like Médecins Sans Frontières (Doctors Without Borders) to pursue creative ways of training and supporting nurses. One result has been onsite training to expand nurses’ use of different contraceptives, including the intra-uterine device, meaning that women are given a wider choice of family planning methods at certain clinics. The strengthening of partnerships between government, clinics and health advocacy groups, particularly in relation to women’s health in the Western Cape, has established new knowledge and support structures for nurses, linking them to other experts who confront similar challenges and enabling them to both provide and gain greater clinical insights.

In many clinics, there remains little time in a day of long queues and steady demands for nurses to counsel their clients thoroughly. It is for these reasons that Zoleka and Nomafu have been employed to counsel abortion patients in Khayelitsha, so as to ease the workload of the nurses at these busy clinics, and to ensure a high quality of service for their patients. Part of this service is in-depth pre- and post-operative counseling on the importance of contraception in helping a woman to prevent an unwanted pregnancy. This is why Zoleka and Nomafu are approached by women in their communities, on the streets and at social gatherings, who are grateful for the counseling they received.

Nomafu explained how most of the young women who seek abortions are still in school, and believe that continuing their pregnancy would prevent them from completing their education, and open them to ridicule from their classmates and teachers. Despite the moral panic about young girls who are supposedly becoming pregnant to get access to child support grants, research on the perceptions of young woman has shown how, for many adolescents, pregnancy while in school is viewed as a profound disruption, associated with economic strain, limited employment prospects, emotional stress and social stigma. In one study, teenage girls who became pregnant reported that they felt ‘ruined’. In Nomafu’s experience as an abortion counselor, many women recounted the resentment of their partners as a reason not to continue with the pregnancy. This anecdotal experience is qualified by research conducted by the Reproductive Rights Alliance, which found that approximately a third of men reacted with ‘anger’ to the news of a pregnancy, and had put pressure on their partners to abort.

Since abortion has been legalized in South Africa, abortion related morbidity and mortality has plummeted by 90%. Whatever a healthcare provider’s moral stance is on abortion, the fact is that its legalization has led to drastic improvements in women’s reproductive health. But despite the fact that abortion is legal, social stigma and the opposition of nurses and others means that abortion is not always accessible for women. This points to the gap between so many of South Africa’s policy commitments in the fields of health and human rights, and the obstruction of these rights when the politics of communities and individuals are at odds with public health or human rights imperatives.

The existence of dedicated counselors helps to ensure that women seeking abortion are given the information they need to make the right decision for themselves about whether to continue or end a pregnancy, and are able to understand the abortion procedure and the mechanics of conception and pregnancy. The support of counselors like Nomafu and Zoleka helps to ensure that these women leave the clinic with the information they need to help prevent another unwanted pregnancy. As Nomafu explained: ‘We take the clients to the counseling room and we explain to them what is going to happen. We touch the clients, we hold their hands, and we tell them to relax. When the procedure is over, we sit with the client until she is ready to go home.’

Rebecca Hodes is the Director of the AIDS and Society Research Unit (University of Cape Town).